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Pharmacy Prior Authorization

Pharmacy PA Contacts

Toll-free: 877-537-0722
Fax: 877-537-0720

Mississippi Medicaid Prescribers

Registered Users
If you are a Mississippi Medicaid prescriber, submit your prior authorization requests through the Change Healthcare provider portal.

As of October 1, 2016, all providers should re-register at the following link to submit prior authorization requests:

Those Without Web Portal Access
For Mississippi Medicaid prescribers who are unable to submit prior authorizations through the Envision web portal, fax your request to:

Change Healthcare MS Medicaid Pharmacy PA Unit
Fax: 877-537-0720

Drug Prior Authorization Instructions

Prior Authorization Packets Updated
Brand Name Multi-Source 5/5/2017
Early Refill 5/5/2017
Enteral Nutrition 1/26/2018
EPSDT – Beneficiaries Under 21 3/1/2018
Heterozygous Familial Hypercholesterolemia (HeFH) – REPATHA™ (EVOLOCUMAB) and PRALUENT® (ALIROCUMAB) 5/5/2017
Hepatitis C Therapy 1/8/2018
Homozygous Familial Hypercholesterolemia (HoFH) – REPATHA™ (EVOLOCUMAB) 5/5/2017
Max Unit Override 5/5/2017
Multiple Concurrent Antipsychotics for Beneficiaries (Age < 18) 5/15/2017
PDL Exception Request 5/5/2017
RSV-SYNAGIS® 10/1/2017


Pharmacy Reconsideration Request Form


Pharmacy Prior Authorization – Other Information and Forms